Hemoptysis Due to Diffuse Alveolar Hemorrhage

Audience This scenario was developed to educate junior and senior emergency medicine (EM) residents. Introduction EM Model of Practice recommends that the residents are able to manage patients in a critical condition from massive hemoptysis. Mild to moderate hemoptysis can be self-limiting and often can be managed with conservative measures; however, massive hemoptysis is a life-threatening emergency that needs to be managed promptly. Mortality from massive hemoptysis is about 13%–18%.1 There are several causes for hemoptysis ranging from pulmonary to vascular causes. Diffuse alveolar hemorrhage (DAH) causes hemoptysis only 0.2% which makes it a very rare but devastating disease.2 Hemoptysis from DAH can present a significant challenge to an EM physician since it can present in various ways including chest pain, shortness of breath or hemoptysis. Up to 40% of the patients can present without hemoptysis which makes it a diagnostic dilemma.3 Patients presenting with massive hemoptysis from DAH require management for hypovolemic shock, hypoxic respiratory arrest and potential cardiac arrest. The physicians also need to perform adequate ventilator management to help with alveolar recruitment. This simulation case can help discuss some of the nuances of the management of hemoptysis and DAH. Objectives By the end of this simulation session, learners will be able to: (1) recognize worsening respiratory status of a patient with hemoptysis and intervene appropriately, (2) manage a patient with severe hemoptysis and perform appropriate ventilator management, (3) manage sinus tachycardia with QT prolongation on the ECG caused by cocaine and hypomagnesemia, (4) address various etiologies of hemoptysis, (5) discuss the causes of massive hemoptysis and management options, and (6) review ventilation strategies in an intubated hypoxic patient. Educational Methods This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. Each session had 3 EM residents from various levels of training on the team and 7 observers. There was 1 simulation instructor running the session and 1 simulation technician who acted as a nurse. Research Methods After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right amount of complexity, (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. A Likert scale was used to collect the responses. Results Seven learners responded to the survey. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning and improving patient care. They also agreed that it helped in improving medical knowledge. The post-session debrief was found to be very helpful by all the learners. Discussion High-fidelity simulation was a cost-effective yet realistic way to manage severe hemoptysis, PEA (pulseless electrical activity), and persistent hypoxia in patients with diffuse alveolar hemorrhage. Starting the case with severe hypoxia that quickly progresses to PEA helps the learner to manage the patient quickly and effectively. Overall, learners enjoyed managing the patient, followed by discussing the various management strategies. Topics Hemoptysis, diffuse alveolar hemorrhage, medical simulation, respiratory.


Linked objectives and methods:
Chest pain and shortness of breath are the bread and butter of EM and the etiologies of each can vary tremendously. This case starts with the patient presenting with both chest pain and shortness of breath which allows the learners to maintain a broad differential and avoid anchoring. Learners are expected to recognize the worsening respiratory status and hypoxia and intervene in a timely fashion (Objective #1). Learners are further challenged by the patient going into PEA arrest requiring them to follow ACLS (advanced cardiac life support) protocol. After return of spontaneous circulation (ROSC), patient will continue to be hypoxic due to worsening alveolar hemorrhage, and the learners will need to perform appropriate ventilator management (Objective #2). In a patient with cocaine abuse, ECG changes and electrolyte abnormalities are common. This case requires learners to recognize and manage sinus tachycardia with QT prolongation on ECG caused by cocaine and hypomagnesemia (Objective #3). In addition, learners are expected to administer antibiotics and steroids to cover for the etiologies of patient's respiratory status. Patients with severe hemoptysis need a bronchoscopy to stop the bleeding. Thus, the learners will need to consult a critical care pulmonologist/intensivist from bronchoscopy and to disposition (Objective #4). During the debriefing session, the learners will be expected to discuss the wide range etiologies of massive hemoptysis and management options (Objective #5). They will also need to discuss how they managed the ventilator during the case, or what they could have done to improve patient's hypoxia (Objective #6).
Recommended pre-reading for instructor: patient is being switched over from a nasal cannula to nonrebreather mask, the O2 saturation will rapidly start going down to allow for PEA arrest and also to prompt the learners to intubate. After ROSC, O2 saturation will need to stay low to prompt the learners to do ventilator management. Novice learners may need prompting to manage post-intubation persistent hypoxia, to obtain CT of the chest, and to administer steroids and antibiotics. After the simulation and debriefing session were complete, an online survey was sent via surveymonkey.com to all the 9 participants. The responses were collected on a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree." The survey collected responses to the following questions: All of the respondents either agreed or strongly agreed that the case was beneficial in learning and in improving medical knowledge and patient care. They also agreed that it had the right amount of complexity. Two respondents were neutral while 5 agreed or strongly agreed that the case gave them a real-life experience. The post-session debrief was found to be helpful by all the respondents.

Case Description & Diagnosis (short synopsis):
A 35-year-old male brought in by emergency medical services (EMS) to the emergency department (ED) for sudden onset chest pain and shortness of breath. He initially complains of coughing up only a spoonful of blood. Upon further questioning, he states he had done some crack cocaine after which all of these symptoms had started. He also admits that he has been coughing up blood for several months now. The patient is initially tachypneic and hypoxic and was placed on nasal cannula by EMS. Upon arrival to the ED, he speaks in a few words and is visibly short of breath. He is coughing up blood clots while getting more hypoxic. He refuses placement of non-rebreather or noninvasive positive pressure ventilation (NIPPV). As the hypoxia worsens, the patient will go into pulseless electrical activity. After intubation and ROSC, patient will continue to be hypoxic due to worsening hemorrhage requiring recruitment maneuvers and ventilator management.

Equipment or Props Needed:
High-fidelity simulator Basin with red colored gel for hemoptysis Airway supplies: -Nasal cannula -Non-rebreather mask -Laryngoscope and blades -Endotracheal tube and stylet -Bag-valve mask IV supplies: Initial chest radiograph (CXR) #10 Post-intubation CXR #11 Computed Tomography (CT) scan of the chest Background and brief information: A 35-year-old male brought in by EMS to tertiary care center for sudden onset chest pain and shortness of breath.

Initial presentation:
The patient is brought in by EMS and he complains of shortness of breath. He starts coughing up blood clots upon arrival. In addition, he has tachypnea, tachycardia, and is hypertensive.
How the scene unfolds: Upon arrival to the ED, the learners should start by assessing the patient's respiratory status and airway. They may choose to switch from nasal cannula to nonrebreather and may discuss placing the patient on NIPPV. However, patient will continue to get more short of breath, hypoxic and confused, and refuses any masks on the face. The learners will have to discuss intubation when the patient inevitably goes into PEA as hypoxia worsens. The learners will need to perform cardiopulmonary resuscitation (CPR), administer epinephrine and prepare to intubate the patient. After intubation and bagging the patient, History: • History of present illness: EMS reports that they got called for sudden onset chest pain. He was getting more short of breath and started coughing up blood on the way to the hospital. They obtained a 12-lead ECG.
Patient is able to provide history in 1-word sentences. Chest pain is sharp, middle of the chest. Pain worsens with breathing. He also complains of shortness of breath which started after the chest pain. He also coughed up some blood in the sputum on the way to the ED. The sputum was completely bloody when he coughed it up today. He denies any fever, chills, abdominal pain, nausea, vomiting, headache, or chills. He also denies any trauma to the chest.
If asked, patient reports that he had snorted crack cocaine and he started experiencing chest pain shortly after. He has been having cough with bloody sputum for some time now. He has not seen a physician in a long time.

Monitor display (vital signs)
If the learners attempt to intubate prior to patient going into PEA, the patient will progress to PEA while intubation is happening.
If the learners attempt to intubate, the patient will quickly desaturate into the 50's and progress into PEA arrest. 7:00-8:00 Recognize PEA PEA will occur as the patient becomes more hypoxic and attempts at intubation are made.
If PEA is not recognized, nurse may prompt saying, "I don't feel a pulse" or "He is not responding." In the ED, workup should include ruling out emergent causes of the hemoptysis. Therefore, CBC with differential, metabolic panel, blood cultures, blood gases, erythrocyte sedimentation rate, C-reactive protein, urinalysis, urine drug screen and CXR aid in diagnosis of the underlying cause and complications. 5 CT scan of the chest with IV contrast can help in determining the extent of the lung involvement and in ruling out infection, tumor, or pulmonary embolism. CXR may show diffuse infiltrative opacification with predilection towards the mid-zones. CT scan may show ground-glass opacities or consolidation. 6 If the patient has underlying autoimmune disease or associated pulmonary or renal disease, specific antibodies for these diseases may be ordered.
Management in the ED includes focusing on airway, breathing and circulation (ABCs). Patients with massive hemoptysis will require immediate endotracheal (ET) intubation. CXR can be helpful in determining which lung may be bleeding more. Airway management strategies for massive hemoptysis are discussed in a separate section below. In addition to airway management and ventilation, patients may require intravenous fluid and packed red blood cell administration. The underlying causes of hemoptysis need to be addressed including steroid or antibiotic administration, coagulopathy reversal or anticoagulation. After resuscitation, bronchoscopy can be both diagnostic and therapeutic. 7,8 Diffuse Alveolar Hemorrhage (DAH) DAH occurs in the pulmonary microcirculation; it is specifically characterized by bleeding into the alveoli. There are a variety of disorders associated with DAH; however, it is marked by 3 distinct pathologies of the lung: 1) Pulmonary capillaritis, 2) Bland pulmonary hemorrhage and 3) Diffuse alveolar damage. 9 Pulmonary capillaritis is characterized by neutrophilic infiltration, fibrinoid necrosis of alveolar and capillary walls, and anti-glomerular basement membrane disease. Pathologic capillaritis is Bland pulmonary hemorrhage is defined by red blood cells leakage into the alveoli without any inflammation or damage of the alveolar structures. Bland hemorrhage is generally associated with bleeding disorders, anticoagulant therapies, elevated end diastolic pressures, and can occasionally be caused by Goodpasture's syndrome and inhalation drugs such as crack cocaine. Diffuse alveolar damage causes the formation of alveolar edema and intra-alveolar hyaline membrane. Diffuse alveolar damage is the underlying pathology associated with acute respiratory distress syndrome (ARDS). A variant of ARDS caused by crack cocaine is often termed "crack lung." 10,11 Clinical presentation can include hemoptysis, anemia, and respiratory failure. However, up to a third of patients present without any hemoptysis due to the resorptive capacity of the lungs. Some of the other non-specific symptoms include cough, dyspnea, chest pain, and fever. 10 Frequent chest radiograph findings include diffuse or patchy opacities. Laboratory studies are non-specific but may help with making the diagnosis. These laboratory studies include a complete blood count with evidence of anemia, an arterial blood gas which can demonstrate the level of hypoxia, and other studies indicating coagulative dysfunction such as prothrombin time. Specific antibodies such as anti-nuclear antibody (ANA), cytoplasmic or peripheral antineutrophil cytoplasmic antibodies (C-ANCA or P-ANCA) can be considered to guide further testing. 11 Treatment of DAH is symptomatic and primarily focuses on addressing ABCs as discussed above. In a patient with known history of underlying autoimmune disorders, methylprednisolone 500-2000mg and cyclophosphamide 2mg/kg can be administered. Intubation and ventilation is frequently required in DAH. 10 However, ventilation may prove difficult in patients with severe alveolar hemorrhage and associated ARDS. 12 Recruitment maneuvers such as ARDSnet low tidal-volume ventilation and Airway Pressure Release Ventilation (APRV) may be attempted. 12,13 ARDSnet focuses on high positive end expiratory pressures in order to recruit and maintain open alveoli whereas APRV is a less commonly known inverse ventilation method that gives a high level of continuous pressure and intermittently releases the pressure to allow expiration. 13